AIRTIGHT is a pragmatic, randomized quality improvement evaluation. Patients who are identified by risk modeling as having a high risk (>20%) for a 30-day readmission will be eligible for CHS-TS referral (referral eligible). Each weekday, referral eligible patients will be randomly assigned to CHS-TS referrals with a total number targeted to the CHS-TS's capacity. The CHS TS capacity will be revaluated on a daily. Because variables that affect eligibility may change throughout the course of a hospital stay, exclusion criteria are applied again at the time of discharge for the purposes of analysis. For example, patients not discharged to home are excluded. A diagnosis of heart failure is also added as an additional exclusion criterion at the time of discharge because CHS Heart Success recruits patients from a similar population and there is significant overlap in the services offered between CHS TS and CHS Heart Success. All patients who remain eligible at the time of discharge (discharge eligible) will be included in the analysis. Planned enrollment is 1520 patients (n=760 per arm) with the engagement in CHS-TS services ending at the 30th day after discharge. Outcomes data will be tracked for 90 days. To mitigate the risk of selection bias, all eligibility criteria are objective and determined using data analytics within the software package, SAS. Additionally, analysis will be by intention to treat. With the use of this pragmatic design, crossovers from the CHS-TS arm to usual care are expected and may attenuate the measured effect of the CHS-TS. Since this evaluation protocol is part of a quality improvement intervention, the investigators requested that the CHS institutional review board designate the study as expedited research and grant a waiver of informed consent.